Transcript Treatment options for Patients with Opioid Use Disorder

Treatment Options
for
Opioid Use Disorder
William J. Lorman, JD, PhD, MSN, PMHNP-BC, CARN-AP
V. P. & Chief Clinical Officer, Livengrin Foundation, Inc.
Ass’t Clinical Professor, Doctoral Nursing Dept.,
Drexel University
[email protected]
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MEDICATION ASSISTED TREATMENT:
AN OVERVIEW
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Goals For Pharmacotherapy
• Prevention or reduction of withdrawal symptoms
• Prevention or reduction of drug craving
• Prevention of relapse to use of addictive drug
• Restoration to or toward normalcy of any
physiological function disrupted by drug abuse
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Treatments - Pharmacological
• Short-Term (Less than 30 days)
• Relief of withdrawal
• Withdrawal Management (Detoxification)
• Opioid and non-opioid
• Long-Term (30-180 days)
• Opioid agonist
• Opioid antagonist
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Objectives of Maintenance Treatment
• To reduce mortality from overdose and infection
• To reduce opioid and other illicit drug use
• To reduce transmission of HIV, HBV and HCV
• To improve the general health and well-being of
patients
• To reduce drug-related crime
• To improve social functioning and ability to stay
in work
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Public Expectations of Substance Abuse
Treatment Interventions
• Safe, complete detoxification
• Reduce use of medical services
• Eliminate crime
• Return to employment/ self support
• Eliminate family disruption
• No return to drug use
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Treatment Options
• Pharmacologic treatment options:
– Methadone
– Buprenorphine
– Naltrexone
– Alpha adrenergic agonists (clonidine)
• Psychosocial support
– 12 step programs
– Cognitive Behavioral Therapy, Motivational
Enhancement Therapy, etc.
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Choosing Maintenance Medications
• No evidence that certain patients respond better to
buprenorphine/methadone
• The choice between methadone or buprenorphine depends upon:
– Overall response to each treatment
• Many patients express a clear preference
– Access to treatment setting (e.g., doctor’s office vs Opioid Treatment
Program)
– Ease of withdrawal
– Patient (and clinician) expectancy
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Buprenorphine:
Not all patients are suitable
 Contraindication for buprenorphine treatment:
 Hypersensitivity to buprenorphine or naloxone
 Age < 16 years
 Access to specialty treatment services may be
required:
 Pregnancy
 Unstable dual diagnosis/psychiatric co-morbidity
 Unstable polydrug use (especially benzodiazepines and CNS
depressants)
 HIV/HCV with acute hepatic dysfunction
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Staying in Treatment
• Pharmacologic treatment in combination with
psychosocial interventions significantly enhances
treatment effectiveness:
– Retention after 1-year treatment, 75% and 0% in
buprenorphine and placebo groups respectively (Kakko et al,
2003)
• Pharmacotherapy helps patients stay in treatment:
– Reduces illicit drug use due to decreased cravings and
withdrawal symptoms
– Reduces mortality by up to 4-fold (Kreek & Vocci, 2002)
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Buprenorphine Products
• Buprenorphine Monotherapy
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Buprenex Injection (not indicated for MAT)
Subutex SL tablet
Probuphine Subdermal Implant
Butrans Transdermal Patch
• Buprenorphine/Naloxone Combination Therapy
• Suboxone SL tablet and film
• Zubsolv SL tablet
• Bunavail Buccal film
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Other Medications Approved for
Treatment of Opioid Dependence
• Agonist substitution therapies
– Methadone
• 179,000 patients receive this type of treatment in the US (American
Methadone Treatment Association, 1999)
• Produces morphine-like agonist effects and cross substitute for
heroin.
• Antagonist therapy
– Naltrexone
• Does not produce morphine-like subjective effects
• Difficult to retain patients in treatment due to a lack of desired
positive subjective effects
• Used relatively infrequently compared with agonist therapy
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Dosing of Traditional Medications
• Methadone
– The dose is increased until opioid craving, illicit opioid use, and
withdrawal symptoms have abated, or, until excessive side-effects
(i.e., sedation, constipation, etc.) require a reduction in dose
• Naltrexone
– Dosed on a daily or thrice-weekly schedule to produce blockade
of illicit opioids
– Buprenorphine
– Dosed between 4 and 32 mg/d.
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Naltrexone
• Long-acting opioid antagonist
• Provides complete blockade of opioid receptors when taken at
least three times a week
• Total weekly dose of about 350 mg.
• Treatment retention rates are 20-30% over 6 months.
• Factors for poor retention:
• Does not provide narcotic effect
• Cravings may continue during treatment
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Naltrexone (continued)
• Initiated following acute withdrawal from opioids
• Seven to 10 day opioid free period
• Initial dose generally 25 mg (1st day) – GI side effects
• Then 50 mg daily or 100mg every other day or 350 mg weekly (in
3 divided doses)
• Most serious side effect is liver toxicity
• If patient uses an opiate while on Naltrexone, it will have no
effect.
• VIVITROL: Monthly injection – 380mg
• Surgical implant also available
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Naltrexone
• Blockade produced is competitive. Can be
overcome by using increasing amounts of the
opiate.
• Relatively fine line between the amount of
opiate it takes to overcome the blockade and
the lethal dose.
• Usage has been most successful in populations
who are highly motivated and are not likely to
try to overcome the blockade (individuals with a
good support system, professionals, etc.).
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METHADONE
• May only be prescribed in the community for
opiate addiction treatment by physicians’
affiliated with an CSAT accredited Methadone
Maintenance Treatment Program.
• Federal and State regulations govern its
utilization within these programs.
• Specific criteria must be met in order to be
admitted to a program.
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METHADONE
 Rationale for long-term methadone maintenance:
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Ability to relieve protracted abstinence syndrome
Block heroin euphoria
Psychosocial stabilization
Reduced criminal activity
 No serious side effects
 Mainly constipation, sweating, drowsiness, decreased sexual
interest/performance
 Safe during pregnancy
 Today’s high-purity street heroin has required even higher
methadone doses to achieve cross-tolerance
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Methadone-Benefits
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Produces tolerance to other opiates.
Can be given in a single daily dose (24 hour half life).
Reduces opiate cravings.
Prevents emergence of opiate physical withdrawal symptoms.
Requires patient to be involved in ongoing formal treatment.
Results in increased employment, improved physical and
mental health, and improved social functioning.
• Pt’s involved in MM programs have a significantly reduced rate
of seroconversion to HIV disease.
• No long term physical or mental complications have been
identified.
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Methadone-Issues
• Patients need to go to MM clinic daily to get their
medication. May limit social activities.
• Patients remain physically dependent on Methadone.
• MM patients are often discriminated against in housing
and other social programs.
• Patients are often not welcomed at community self-help
support groups (i.e. NA) due to their use of Methadone.
• Side Effects: Most common problems are chronic
constipation and excessive sweating.
• Duration of treatment: Felt to be long term in most cases.
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Some Principles of Substitution
Management
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Select Appropriate Patients
• Minimum age of 18 years (generally)
• At least one year of physiologic dependence on a narcotic
• Meets criteria for opioid dependence
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Prevent Relapse
• Educate patient and family about potential for relapse
• Encourage involvement in Narcotics Anonymous and Nar-Anon
• Monitor patient for symptoms of opioid intoxication or drugseeking behavior
• Adjust dosage according to needs
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Evaluate & Treat Medical Conditions
• Infectious Disease
• Reduce risk of contracting and transmitting disease
• Educate family and involve them in preventive efforts
• Pain Management
• Consider non-narcotic agents first
• Evaluate cross-tolerance in narcotic analgesia
• Avoid narcotics that induce withdrawal
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Drugs That Interact with Methadone
Induction
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Rifampin
Pehnytoin
Ethyl Alcohol
Barbiturates
Carbamazepine
St. John’s Wart
Inhibition
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Fluconazole
Cimetidine
Erythromycin
Fluvoxamine
Fluoxetine
Ketoconazole
Nefazadone
Ritonavir
Clomipramine
Haloperidol
Paroxetine
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PSYCHOSOCIAL SERVICES
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Cycle of Opiate Addiction
Drug Use
Obtain drugs
Physical dependence
Obtain money for drugs
Withdrawal symptoms
Need for drugs
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Planning Care
• Developed through collaboration among the addictions nurse,
the multidisciplinary treatment team, the patient and
significant others.
• The plan of care:
• Addresses priorities first
• Incorporates principles of appropriate treatment
• Includes specific interventions that reflect current science and
evidence of effectiveness
• Includes health education
• Designates a discharge plan
• Includes strategies for health promotion and restoration of health
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Implementation of Care
• Interventions are based on problem identification
• Interventions include:
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Detoxification as needed
Appropriate administration of pharmacologic therapies
Development of a therapeutic relationship
Maintain safety
Health teaching
Involvement of patient in goal setting
Attention to family issues
Referral for ongoing support
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Evaluating Care
• Document the patient’s responses to interventions
• Examine the patient’s progress toward attainment of
outcomes
• Use ongoing assessment data to revise plan of care as needed.
• Involve the patient, significant others, and other healthcare
providers in the evaluation of care.
• Ensure that evaluation is an ongoing process.
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Strategies to
Improve
Treatment Adherence
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Psychosocial Support for Patients
• Educate the patient about his or her addiction and help him or
her make appropriate behavioral and lifestyle changes
• Refer to 12-step alcohol or narcotics abuse programs
• Require SUD-IOP at a minimum
• Empathize with the patient’s emotional discomfort during the
treatment process
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Focus on Behavior Change
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Scheduling time to participate in new activities
Participating in regular physical activity
Making positive nutritional or dietary changes
Participating in 12-step alcohol or narcotics abuse programs
Gradually increasing responsibilities
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Patient Education
• Behavior change is essential to recovery. The
patient should also understand the following facts
about buprenorphine use:
• How it works to treat opioid dependence
• The risk of overdose when buprenorphine is combined
with alcohol or other drugs, such as diazepam
• While taking buprenorphine, the effects of heroin and
other opioids will be somewhat blocked, and trying to
overcome the blockade by using more heroine may
result in a lethal overdose
• After buprenorphine use is discontinued tolerance to
opioid is likely to decrease and a heroin overdose may
occur if heroin is used
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